Application Form for Wholesale Internet Presence

Reseller Company Name

Reseller Phone #

First Name of Contact Person

Last Name of Contact Person

Reseller Billing Street Address

Reseller City

Reseller State or Province

Reseller Zip Code

Reseller Country

Reseller Fax #

Reseller's Client Account Name

Website Name Request (4-12 digits)

MB of storage

MB

Password Request (6-8 digits)

Email

Email Name Request (3-20digits)

@wwz.com

     

Print and sign the agreement below. Fax it to us at (773) 286-1992. You may also fax the credit card form or call us with the information at (800) 708-1016.

CLIENT AGREEMENT

This agreement is between EMERgency 24, Inc. and ___________________________, hereinafter referred to as Client. The purpose of this agreement is to set forth the terms for World Wide Web publishing space on the Internet by Client on EMERgency 24's Web server. Client is responsible for the content of its documents. Client will insure that no document contains obscene, pornographic, slanderous or any illegal material, or information promoting illegal activity. Charges for the Client's Website and activity are anticipated based on history and billed quarterly in advance. Invoices will be sent by EMERgency 24 to the Client on or about the 5th of the month. Payment may be made by Visa/Mastercard (automatic payment plan) or check and is due by the 1st of the following month. Payments should be mailed to: EMERgency 24, Inc., 4179 W. Irving Park Road, Chicago, IL 60641-2906. Payment is considered late on the 10th of the following month, and a late fee up to 5 percent of the total amount due will be assessed. If payment is not received by the 15th of that month, Client 's documents are subject to removal from the EMERgency 24 server.

Signed: ________________________________________Title: ______________________________

Date: ______________________________

Secure Credit Card Information

Name on Credit Card Credit Card Number
Credit Card Issuer Expiration date